We conducted a retrospective study that analyzed cases of STI – Associated Syndromes assisted in a primary health care center from 1999 to 2008. We considered for this study, the STI – Associated Syndromes established by the MH of Brazil (ulcer, discharges, warts and pelvic pain) .
The health care unit is part of an internship program where students from public and private universities of Fortaleza perform practical activities and it is also a place for research by national and international institutions. It holds an average of 120,428 consultations, and among these, 687 are consultations of people with genital complaints. It is, therefore, an ideal place for this research due to its care management and the availability of records on STI – Associate Syndromes.
The study took place in Fortaleza, capital of Ceará state, located in Northeast Brazil, where health care services are provided free of charge by the Brazilian National Health System (SUS). This system is a result of the struggle of social movements and was created after the Brazilian Constitution of 1988. One of its principles is to assure that health care is provided, free of charge, for everyone. In Fortaleza, this service is composed of 1116 health care units, 396 health care centers, 252 hospitals and also public and private laboratories and blood banks.
In the mid-90’s, a convention among the University of Bordeaux and the Ministry of Health and the Departments of Health Care Services of Ceará and Fortaleza was signed for the implementation of care services for STI – Associated Syndromes through the syndrome management. This convention enabled the continuous education and training of professionals with emphasis on reception and counseling. It also enabled the acquisition of medicines, material and the internal patient flow management. Since then, the health care unit keeps all the resources available, especially medicines and the technical support for the collection of serologies for syphilis and HIV after consultations.
From 1999 to 2008, the unit assisted 6872 people with genital syndromes. We analyzed the cases that presented only one STI – Associated Syndrome (ulcer, discharges, warts, pelvic pain). Then, 1724 people who presented more than one genital syndrome were excluded. The remaining 5148 cases were analyzed in this study.
The data collection was done through the specific forms for services for STI and patients’ records. This form was implemented in the unit in 1999 and since then it is filled and typed everyday by a professional who is specifically in charge of it. The data that were not in the forms and records were classified as ignored. The cases of Hepatitis B and C were not analyzed because such tests were not performed in the unit during the period that it was studied.
The returns of these patients for reassessment are scheduled according to the time the results of the VDRL and Anti-HIV tests come out (seven days for VDRL and thirty days for Anti-HIV). In this study, we considered that the patient returned to the unit for reassessment within three months from the first consultation.
Biological specimens and serology
The syndrome management of STI – Associated Syndromes aims to provide in a single consultation, the diagnosis, treatment and counseling in order to immediately break the transmission chain effectively [14, 15]. In Brazil, all the flowcharts recommend as a complementary action the serology tests VDRL, HIV and Hepatitis B and C along with counseling, as well as the notification and treatment of sexual partners.
The quantitative and qualitative VDRL tests are collected and done in the unit. We considered reactive for syphilis all patients with reactive VDRL equals to or higher than 1:2, since they haven’t presented previous treatment. The VDRL is an available test that is largely used in primary health care in Brazil, mainly due to its simplicity and low-cost. It’s worth saying that Brazil aims to control congenital syphilis and all efforts have been made to identify suspected cases of syphilis, which justifies the serological diagnosis through non-treponemic tests and the treatment of reactive cases in places where confirmatory tests are unavailable .
The serological sample for Anti-HIV is collected in the health center after informed consent is obtained during counseling. After collection, the material is sent to the state of Ceará reference laboratory (Central Laboratory of Ceará – LACEN), responsible for most of the serological diagnoses of HIV infections in the State and that has always met the technical rules standardized in the MH of Brazil . This diagnosis is performed in two stages: a classification through the Enzyme Linked Immunoabsorbent Assay (ELISA) technique and, regarding the result, a complementary with the Indirect Immunofluorescence (IFI) technique. The medical report comes out when the results are positive in stages I and II.
Brazilian rules require the collection of a second blood sample to prove laboratorial diagnoses of positive cases. The collection must be performed during the delivery of the first reactive sample. It’s worth saying that the second sample undergoes only through stage I of the flowchart. In this study, the reactive cases were the ones which the results were positives in the first and second sample.
Non-reactive results in the first stage are released and taken to the health care center to be delivered to patients, with a post-test counseling when a second blood sample collection is required after 30 days, in case the patient is in the immunological window period.
We considered as dependent variables the types of syndromes and the VDRL and Anti-HIV tests because they were part of the daily health care of patients with STI – Associated Syndromes. The independent variables were city of residence, sex, age (years), schooling (studying years), return for reavaliation and number of sexual partners in the past three months, once these information were in the standardized consultation forms.
The data were typed in the statistical package Epi-Info 6.04 (Centers for Disease Control and Prevention – CDC - Atlanta, Georgia, USA) and analyzed in the software SPSS 19.0 (IBM Company, Chicago, USA). We used Pearson’s Chi-square test to analyze the differences among the categorical variables, with a significance level of 5%. A multivariate analysis was performed by the statistical package STATA 11.0 (Stata Corp LP, College Station, TX 77845, USA), through a logistic regression model, using the stepwise technique. For the adjusted analysis we considered the variables with p values p <0.05. We used the Odds Ratio (OR) with a 95% confidence interval as an effect size. The syndromes assessed in the logistic regression were warts and genital ulcers, since they occur in both men and women.
The study as approved by the Ethics in Research Committee of the Public Health School of Ceará according to Protocol no 126/2008.